Special Smiles New Patient Intake Form

Patient Name*

First NameLast Name

Sex*

MaleFemale

Patient Date of Birth*

Date

Social Security Number*

Primary Dental Insurance Name (if other than State Insurance)*

Primary Insurance Member ID*

Primary Member Name: *

Primary Member Date of Birth*

Date

Secondary Dental Insurance Name (State Insurance)

Secondary Insurance Member ID

Does Patient reside at (select one)*

HomeFacility

Name of Facility

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does the patient live at residence by themselves?*

YesNo

If yes, be advised that after receiving general anesthesia patient would need to continuously be observed for 24 hours.

Contact Name*

First NameLast Name

Relationship to Patient*

Contact Phone Number*

Contact Secondary (Cell):

Contact Email*

example@example.com

Name of Legal Guardian*

First NameLast Name

Name of Person Who Signs Consents*

First NameLast Name

Legal Guardian Telephone*

Please enter a valid phone number.

Legal Guardian Secondary (Cell)

Please enter a valid phone number.

Previous Referring Dentist Name*

Previous Referring Dentist Phone Number*

Please enter a valid phone number.

Primary Care Physician*

Primary Care Physician Phone Number*

Please enter a valid phone number.

List all medical diagnoses/condition (example: IDD, Downs Syndrome, etc..): *

Patient Weight*

lbs.

Patient Height*

ft. and in.

Is the patient experiencing oral pain, swelling or redness? Please circle:*

YesNo

If yes, please proceed to the nearest emergency department for urgent treatment and then contact Special Smiles, Ltd. the next business day in order to schedule an initial consultation.

Is the patient edentulous (without teeth)?*

YesNo

Date of last Dental Visit*

Date

Is the patient cooperative for dental treatment?*

YesNo

Was dental treatment completed while patient (please check)*

Was awakeWith sedationUnder general anesthesia

What type of dental treatment was completed?*

Are there any contraindications to general anesthesia?*

Are there any medical and/or dental concerns that need to be addressed at the initial consultation?*

Which of the following describes the patient? (please check)*

In a wheelchairIn a stretcherCompletely mobile

* If Patient resides at a Facility please send completed form along with a current Lifetime Medical History, Med List, Insurance Cards and Referral. Referrals are required for gu new patients. Referral must say: Reason for visit, General Anesthesia is necessary and if patient will remain at Special Smiles for all future treatment.